The name of the deceased and any identifying information are suppressed from publication. The deceased is to be referred to as Baby Z

Summary : At the time of his death the deceased was in the care of his mother, who was a sentenced prisoner at the Bandyup Women’s Prison. The deceased was born at King Edward Memorial Hospital. The Department of Child Protection and Family Support were actively involved with the deceased’s mother prior to his birth and after his birth. The deceased and his mother returned to Bandyup Prison and were housed in the Nursery Unit. The deceased was permitted to stay with his mother as a “visitor”. There were no significant concerns raised about the deceased’s health or care while at Bandyup until he was found deceased by his mother at around 3:30am on 3 April 2011. He was one month old.

Given the circumstances of the deceased’s death, his death is treated as a death of a person held in care, thus requiring an inquest to be held into his death pursuant to section 22(1)(a) of the Coroners Act 1996 (WA).

The issues which were identified as primary areas for consideration at the inquest were: what protocols were in place for information sharing between King Edward Memorial Hospital, Bandyup Prison and the Department of Child Protection and Family Support and were they followed? Did all of the relevant parties have the necessary information about the deceased and his mother to properly consider the decisions to allow the deceased to be discharged from hospital and allow him to reside with his mother at Bandyup? What did the relevant parties do to ensure that the deceased was appropriately monitored once he was at Bandyup?

The deceased’s mother was spoken to on a number of occasions to try to get a clear account of what occurred on the night the deceased died. Her version of events remained generally consistent, however, she was uncertain as to the sleeping location and position of the deceased at the time she found him unresponsive. In respect to whether or not the deceased was in his cot at the time he was found it was unclear from the various accounts given by his mother. The Coroner concluded that the evidence overall suggests that, rather than deliberately lying to police, with a knowledge that the deceased was not in his cot that night, the deceased’s mother had no clear recollection of what occurred on that night. The Coroner heard evidence that the deceased’s mother had been seen co-sleeping with the deceased on occasions. After considering the evidence the Coroner was satisfied that the deceased’s mother did engage in co-sleeping with the deceased on occasions, but there is insufficient evidence to make a finding that the deceased was co-sleeping with his mother at the time he died.

A post mortem examination was performed on the deceased and examinations revealed an apparently normally developed male infant with no evidence of significant natural disease or injury to account for his death. Extensive further investigations were carried out to try and establish a cause of death. Despite going to great lengths to try to exclude as many factors as possible, there were no findings that could positively account for the death. The cause of death was unascertained. The Coroner found that given the cause of death could not be established it was not possible, therefore, to reach a conclusion as to the manner of death. Accordingly, the Coroner made an open finding as to the manner of death.

The Coroner concluded that on 3 April 2011 the deceased died suddenly while residing with his mother at Bandyup Women’s Prison. The Coroner noted that the evidence indicated that overall the systems which are in place to manage mother and newborns in the Western Australian prison system are well-designed and implemented, although noting that there is always room for improvements. The Coroner observed a number of government agencies who were involved in the deceased’s short life, including staff at King Edward Memorial Hospital, Department of Child Protection and Bandyup Women’s Prison, all acted to the best of their abilities to ensure that the deceased remained safe and well, while maintaining a bond with his mother.

In conclusion, the Coroner found that despite some communication failures, the overall management of the deceased’s treatment, care and supervision in his few weeks of life was of a high standard and his tragic death cannot be attributed to any of the agencies involved in his care.